=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720596216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDI NICOLE INGERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2018
-----------------------------------------------------
Last Update Date | 01/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 N CUNNINGHAM AVE LOCATED IN LEONE CHIROPRACTIC
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-384-8180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 N. CUNNINGHAM AVE. LOCATED IN LEONE
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-384-8180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227014032
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------